Skip to main content

Main menu

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums

User menu

  • My alerts

Search

  • Advanced search
The College of Family Physicians of Canada
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums
  • My alerts
The College of Family Physicians of Canada

Advanced Search

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • RSS feeds
  • Follow cfp Template on Twitter
Research ArticlePractice

APNEIC: an easy-to-use screening tool for obstructive sleep apnea

Navindra Persaud
Canadian Family Physician September 2010, 56 (9) 904-905;
Navindra Persaud
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF
Loading

Identifying patients who are likely to have obstructive sleep apnea (OSA) is vital. As overnight polysomnography, the criterion standard diagnostic test, is expensive and limited in its availability, many people with OSA, perhaps as many as 93%, remain undiagnosed.1 Effective screening in primary care settings could increase the number of OSA patients identified, who can then be offered continuous positive airway pressure—an intervention that might reduce morbidity and mortality.

I searched the literature and put together the results of the 2 studies that employed findings practical to the primary care setting and that used polysomnography to diagnose OSA.2,3 From these studies, I came up with the mnemonic APNEIC, which can be used to recall the 6 attributes of OSA observed in clinical practice: Age older than 50 years; Pharynx grade III or IV; Neck circumference greater than 35 cm; Excessive weight (body mass index > 27 kg/m2); Incisors forward (ie, overbite); and Cricomental distance less than 1.5 cm (Box 1). Materials required include a tape measure, a ruler, and a scale.

Box 1.

The APNEIC mnemonic for OSA

Age > 50 y
Pharynx grade III or IV
Neck circumference > 35 cm
Excessive weight (BMI > 27 kg/m2)
Incisors forward (ie, overbite)
Cricomental distance < 1.5 cm
  • BMI—body mass index, OSA—obstructive sleep apnea.

  • Taking the measurements

    The Mallampati pharynx grade is obtained by asking patients to open their mouths and stick out their tongues as much as possible. If the pillars of the tonsils are visible then the pharyngeal grade is less than III (Figure 1). Avoid asking patients to say “ah” and do not use tongue depressors, as these maneuvers will cause an underestimation of the pharyngeal grade. Neck circumference is measured at the level of the cricothyroid membrane.

    Figure 1
    • Download figure
    • Open in new tab
    Figure 1

    Grades II and III of the Mallampati pharyngeal grading system. A grade of III or IV applies if the pillars of the tonsils are not seen.

    The presence of an overbite is determined by asking patients to close their mouths normally then retract the lips (ie, “Show me your teeth while keeping them clenched”). If the upper teeth are in front of the lower teeth, an overbite is present. The cricomental space is measured by putting a straight edge (eg, a ruler) between the cricoid cartilage and the inner chin, while the patient holds his or her head in the neutral position. This cricomental distance is then bisected and the perpendicular distance to the skin of the neck is measured (Figure 2).3 Using a thick instrument such as a tongue depressor should be avoided, as it might cause a slight underestimation of the cricomental distance.

    Figure 2
    • Download figure
    • Open in new tab
    Figure 2

    The cricomental space is the distance between the neck and the bisection of a line from the chin to the cricoid membrane when the head is in a neutral position

    Adapted from Tsai et al.3

    If the cricomental distance is greater than 1.5 cm, OSA is very unlikely; in one study, the negative predictive value was 100%.3 If the cricomental distance is less than 1.5 cm, then the other 5 factors should be considered—the more of them that are positive, the more likely a diagnosis of OSA. Tsai et al demonstrated that having a cricomental distance of less than 1.5 cm, a pharyngeal grade of III or IV, and an overbite prompted a positive predictive value of 95% for OSA.3

    Alternative screening tools

    The Berlin questionnaire4 and the STOP questionnaire5 are other screening tools for OSA, which are based on historical attributes (history of loud snoring, history of daytime somnolence, etc); both questionnaires have positive predictive values of approximately 50% and negative predictive values of approximately 70%. The STOP questionnaire, which involves questions about snoring, daytime tiredness, observed apnea, and high blood pressure, is a sensitive screening tool.5 It can therefore be combined with the clinical attributes described above and can be remembered using the mnemonic STOP APNEIC.

    Notes

    We encourage readers to share some of their practice experience: the neat little tricks that solve difficult clinical situations. Praxis articles can be submitted online at http://mc.manuscriptcentral.com/cfp or through the CFP website at www.cfp.ca under “Authors.”

    Footnotes

    • Competing interests

      None declared

    • Copyright© the College of Family Physicians of Canada

    References

    1. 1.↵
      1. Young T,
      2. Evans L,
      3. Finn L,
      4. Palta M
      . Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997;20(9):705-6.
      OpenUrlPubMed
    2. 2.↵
      1. Lam B,
      2. Ip MS,
      3. Tench E,
      4. Ryan CF
      . Craniofacial profile in Asian and white subjects with obstructive sleep apnoea. Thorax 2005;60(6):504-10.
      OpenUrlAbstract/FREE Full Text
    3. 3.↵
      1. Tsai WH,
      2. Remmers JE,
      3. Brant R,
      4. Flemons WW,
      5. Davies J,
      6. Macarthur C
      . A decision rule for diagnostic testing in obstructive sleep apnea. Am J Respir Crit Care Med 2003;167(10):1427-32. Epub 2003 Jan 24.
      OpenUrlCrossRefPubMed
    4. 4.↵
      1. Fietze I,
      2. Quispe-Bravo S,
      3. Schiller W,
      4. Röttig J,
      5. Penzel T,
      6. Baumann G,
      7. et al
      . Respiratory arousals in mild obstructive sleep apnea syndrome. Sleep 1999;22(5):583-9.
      OpenUrlPubMed
    5. 5.↵
      1. Chung F,
      2. Yegneswaran B,
      3. Liao P,
      4. Chung SA,
      5. Vairavanathan S,
      6. Islam S,
      7. et al
      . STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008;108(5):812-21.
      OpenUrlCrossRefPubMed
    PreviousNext
    Back to top

    In this issue

    Canadian Family Physician: 56 (9)
    Canadian Family Physician
    Vol. 56, Issue 9
    1 Sep 2010
    • Table of Contents
    • About the Cover
    • Index by author
    Print
    Download PDF
    Article Alerts
    Sign In to Email Alerts with your Email Address
    Email Article

    Thank you for your interest in spreading the word on The College of Family Physicians of Canada.

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    APNEIC: an easy-to-use screening tool for obstructive sleep apnea
    (Your Name) has sent you a message from The College of Family Physicians of Canada
    (Your Name) thought you would like to see the The College of Family Physicians of Canada web site.
    CAPTCHA
    This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
    Citation Tools
    APNEIC: an easy-to-use screening tool for obstructive sleep apnea
    Navindra Persaud
    Canadian Family Physician Sep 2010, 56 (9) 904-905;

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero
    Respond to this article
    Share
    APNEIC: an easy-to-use screening tool for obstructive sleep apnea
    Navindra Persaud
    Canadian Family Physician Sep 2010, 56 (9) 904-905;
    Reddit logo Twitter logo Facebook logo Mendeley logo
    • Tweet Widget
    • Facebook Like
    • Google Plus One

    Jump to section

    • Article
      • Taking the measurements
      • Alternative screening tools
      • Notes
      • Footnotes
      • References
    • Figures & Data
    • Info & Metrics
    • eLetters
    • PDF

    Related Articles

    • No related articles found.
    • PubMed
    • Google Scholar

    Cited By...

    • No citing articles found.
    • Google Scholar

    More in this TOC Section

    Practice

    • Managing type 2 diabetes in primary care during COVID-19
    • Effectiveness of dermoscopy in skin cancer diagnosis
    • Spontaneous pneumothorax in children
    Show more Practice

    Praxis

    • Rapid recommendations
    • Recommandations rapides
    • Aide à la décision d’utiliser ou non les gliflozines pour l’insuffisance cardiaque avec fraction d’éjection supérieure à 40 %, à l’intention des patients
    Show more Praxis

    Similar Articles

    Navigate

    • Home
    • Current Issue
    • Archive
    • Collections - English
    • Collections - Française

    For Authors

    • Authors and Reviewers
    • Submit a Manuscript
    • Permissions
    • Terms of Use

    General Information

    • About CFP
    • About the CFPC
    • Advertisers
    • Careers & Locums
    • Editorial Advisory Board
    • Subscribers

    Journal Services

    • Email Alerts
    • Twitter
    • RSS Feeds

    Copyright © 2023 by The College of Family Physicians of Canada

    Powered by HighWire